Presence Of Prosthetic Material Research Articles

The Utility of Risk Factors to Define Complicated Staphylococcus aureus Bacteremia in a Setting With Low Methicillin-Resistant S. aureus Prevalence.

Recommended duration of antibiotic treatment of Staphylococcus aureus bacteremia (SAB) is frequently based on distinguishing uncomplicated and complicated SAB, and several risk factors at the onset of infection have been proposed to define complicated SAB. Predictive values of risk factors for complicated SAB have not been validated, and consequences of their use on antibiotic prescriptions are unknown. In a prospective cohort, patients with SAB were categorized as complicated or uncomplicated through adjudication (reference definition). Associations and predictive values of 9 risk factors were determined, compared with the reference definition, as was accuracy of Infectious Diseases Society of America (IDSA) criteria that include 4 risk factors, and the projected consequences of applying IDSA criteria on antibiotic use. Among 490 patients, 296 (60%) had complicated SAB. In multivariable analysis, persistent bacteremia (odds ratio [OR], 6.8; 95% confidence interval [CI], 3.9-12.0), community acquisition of SAB (OR, 2.9; 95% CI, 1.9-4.7) and presence of prosthetic material (OR, 2.3; 95% CI, 1.5-3.6) were associated with complicated SAB. Presence of any of the 4 risk factors in the IDSA definition of complicated SAB had a positive predictive value of 70.9% (95% CI, 65.5-75.9) and a negative predictive value of 57.5% (95% CI, 49.1-64.8). Compared with the reference, IDSA criteria yielded 24 (5%) false-negative and 90 (18%) false-positive classifications of complicated SAB. Median duration of antibiotic treatment of these 90 patients was 16 days (interquartile range, 14-19), all with favorable clinical outcome. Risk factors have low to moderate predictive value to identify complicated SAB and their use may lead to unnecessary prolonged antibiotic use.

Updates in Culture-Negative Endocarditis.

Blood culture-negative infective endocarditis (BCNE) is a challenging condition associated with significant morbidity and mortality. This review discusses the epidemiology, microbiology, diagnosis, and treatment of BCNE considering advancements in molecular diagnostics and increased access to cardiac surgery. BCNE can be categorized into bacterial endocarditis with sterilized blood cultures due to previous antibiotic treatment, endocarditis caused by fastidious microorganisms, and true BCNE caused by intracellular organisms that cannot be cultured using traditional techniques. Non-infectious causes such as nonbacterial thrombotic endocarditis should also be considered. Diagnostic approaches involve thorough patient history; blood and serum testing, including appropriate handling of blood cultures; serological testing; and molecular techniques such as targeted and shotgun metagenomic sequencing. Where available, evaluation of explanted cardiac tissue through histopathology and molecular techniques is crucial. The therapy for BCNE depends on the likely causative agent and the presence of prosthetic material, with surgical intervention often required.

Factors associated with antimicrobial choice for surgical prophylaxis in Australia.

BackgroundCefazolin is the most commonly recommended antimicrobial for surgical antimicrobial prophylaxis (SAP). However, the Australian Surgical National Antimicrobial Prescribing Survey revealed a wide range of antimicrobials prescribed for SAP. Inappropriate use of broad-spectrum antimicrobials is associated with increased patient harm and is a posited driver for antimicrobial resistance.ObjectivesTo describe patient, hospital and surgical factors that are associated with appropriateness of the top five prescribed antimicrobials/antimicrobial classes for procedural SAP.MethodsAll procedures audited from 18 April 2016 to 15 April 2019 in the Surgical National Antimicrobial Prescribing Survey were included in the analysis. Estimated marginal means analyses accounted for a range of variables and calculated a rate of adjusted appropriateness (AA). Subanalyses of the top five audited antimicrobials/antimicrobial classes identified associations between variables and appropriateness.ResultsA total of 12 419 surgical episodes with 14 150 prescribed initial procedural doses were included for analysis. When procedural SAP was prescribed, appropriateness was low (57.7%). Allergy status, surgical procedure group and the presence of prosthetic material were positively associated with cefazolin and aminoglycoside appropriateness (P < 0.05). There were no significant positive associations with glycopeptides and third/fourth-generation cephalosporins. The use of broad-spectrum antimicrobials was the most common reason for inappropriate choice (67.9% of metronidazole to 83.3% of third/fourth-generation cephalosporin prescriptions).ConclusionsVarious factors influence appropriateness of procedural SAP choice. Identification of these factors provides targets for antimicrobial stewardship interventions, e.g. procedures where surgeons are regularly prescribing broad-spectrum SAP. These can be tailored to address local hospital prescribing practices.

A Scoping Review on the Use of Antibiotic-Impregnated Beads and Applications to Vascular Surgery.

Surgical site infection (SSI) presents a ubiquitous concern to surgical specialties, especially in the presence of prosthetic material. Antibiotic-impregnated beads present a novel and evolving means to combat this condition. This review aims to analyze the quality of evidence and methods of antibiotic bead use, particularly for application within vascular surgery. A systematic scoping review was conducted within Embase, MEDLINE, and the Cochrane Registry of Randomized Controlled Trials. Articles were evaluated by 2 independent reviewers. Level of evidence was evaluated using the Oxford Center for Evidence-Based Medicine Criteria and the Cochrane Risk of Bias Tool for Randomized Controlled Trials. The search yielded 6951 papers, with 275 included for final analysis. Publications increased in frequency from 1978 to the present. The most common formulation was polymethyl methacrylate; however publications on biodegradable formulations, including calcium sulfate beads, have been published with increasing frequency. Most publications had positive conclusions (94.2%); however, the data was mainly subjective and may be prone to publication bias. Only 11 randomized controlled trials were identified and all but one was evaluated to be at a high risk of bias. The most common indication was for osteomyelitis (52%), orthopedic prosthetic infections (20%), and trauma (9%). Within vascular surgery, beads have been used primarily for the treatment of graft infection, with freedom from recurrence rates being reported from 41% to 87.5%. Antibiotic-impregnated beads provide a means to deliver high doses of antibiotic directly to a surgical site, without the risks of parenteral therapy. There has yet to be significant high-level quality data published on their use. There is a large body of evidence that suggests antibiotic beads may be used in SSIs in high-risk patients, prosthetic infections, and other complex surgical infections. Important potential areas of application in vascular surgery include graft infection, prevention of wound infection in high-risk patients, and diabetic foot infection.

Endocarditis infecciosa

Infective endocarditis is a disease caused by colonization and proliferation of infectious agents on the endothelial surface of the heart. Its clinical presentation is variable, depending upon conditions of the patient, such as immunosuppression, presence of prosthetic material, intravenous drug use, and the etiologic agent. Diagnosis is usually established through the addition of elements such as medical history, physical examination, results of blood cultures, echocardiography and other aids. We present the case of an adult male who came to the hospital with fever and symptoms and signs of acute heart failure. The presence of a systolic murmur was documented in the aortic area, and the echocardiogram revealed severe valve regurgitation and a vegetating lesion on the bicuspid aortic valve. He required valve replacement and completed antibiotic treatment based on the sensitivity of the Streptococcus mitis strain that was demonstrated in the blood cultures.

A Prospective Analysis of the Association Between Indwelling Surgical Drains and Surgical Site Infection in Plastic Surgery

Many surgeons fear that closed-suction drains serve as a portal for bacterial entry into surgical spaces. Despite a lack of supporting evidence, postoperative antibiotics are often prolonged while drains remain in place. Medical records of all patients who underwent intraoperative Jackson-Pratt drain placement and sterile removal over a 12-month period were prospectively analyzed. Fifty-four patients with 101 drains were included. Drains were in place for 5 to 43 days [mean (SD), 13.5 (6.3) days]. Sixty-three percent of drains had positive cultures. All patients received perioperative antibiotics. Thirty-nine patients received postoperative antibiotics [mean (SD), 13.8 (13.8) days]. There were 2 cases of cellulitis. One patient required reoperation. Sixty-six drains (65.3%) were placed in the presence of prosthetic material. Although nearly two thirds of drains were colonized with bacteria, our wound infection rate was extremely low (5.6%). Thus, closed-suction drains may be left in place for an extended period without increasing the risk of infection, even in the presence of prosthetic material.

Minimally invasive fixation of type B and C interprosthetic femoral fractures

Interprosthetic femoral fractures are rare and raise unresolved treatment issues such as the length of the fixation material that best prevents secondary fractures. Awareness of the advantages of locked-plate fixation via a minimally invasive approach remains limited, despite the potential of this method for improving success rates. Femur-spanning (from the trochanters to the condyles) locked-plate fixation via a minimally invasive approach provides high healing rates with no secondary fractures. From January 2004 to May 2011, all eight patients seen for interprosthetic fractures were treated with minimally invasive locked-plate fixation. Mean time since hip arthroplasty was 47.5 months and mean time since knee arthroplasty was 72.6 months. There were 12 standard primary prostheses and four revision prostheses; 11 prostheses were cemented and a single prosthesis showed femoral loosening. Classification about the hip prostheses was Vancouver B in one patient and Vancouver C in seven patients; about the knee prosthesis, the fracture was SoFCOT B in three patients and SOFCOT C in five patients, and a single fracture was SoFCOT D. Minimally invasive locking-plate fixation was performed in all eight patients, with installation on a traction table in seven patients. Healing was obtained in all eight patients, after a mean of 14 weeks (range, 12-16 weeks). One patient had malalignment with more than 5° of varus. There were no general or infectious complications. One patient died, 32 months after surgery. The mean Parker-Palmer mobility score decreased from 6.2 pre-operatively to 2.5 at last follow-up. Early construct failure after 3 weeks in one patient required surgical revision. There was no change in implant fixation at last follow-up. No secondary fractures were recorded. In patients with type B or C interprosthetic fractures, femur-spanning fixation not only avoids complications related to altered bone stock and presence of prosthetic material, but also decreases the risk of secondary fractures by eliminating stress riser zones. The minimally invasive option enhances healing by preserving the fracture haematoma. Thus, healing was obtained consistently in our patients, with no secondary fractures, although the construct failed in one patient. Level IV.

P68 DAPTOMYCIN NON–SUSCEPTIBILITY IN PATIENTS PREVIOUSLY TREATED WITH GLYCOPEPTIDES FOR PROSTHETIC VALVE INFECTIVE ENDOCARDITIS

P68 DAPTOMYCIN NON–SUSCEPTIBILITY IN PATIENTS PREVIOUSLY TREATED WITH GLYCOPEPTIDES FOR PROSTHETIC VALVE INFECTIVE ENDOCARDITIS

Prospective Follow‐Up of Female Sexual Function after Vaginal Surgery for Pelvic Organ Prolapse Using Transobturator Mesh Implants

Although the use of transobturator mesh implants for pelvic organ prolapse repair has been shown to be safe and effective, concern exists that the presence of prosthetic material in the vagina may adversely affect sexual function. To evaluate the impact of transobturator mesh implantation on sexual function using validated questionnaire. Female Sexual Function Index (FSFI), a validated 19-item questionnaire that assesses six domains of sexual function (desire, arousal, lubrication, orgasm, satisfaction, and pain), was used. The questionnaire was administered preoperatively, and at 3, 6, 12, and 24 months postoperatively. Clinical data were also recorded at each time point. Prospective nonrandomized study including 96 women with pelvic organ prolapse (cystocele, rectocele, vault prolapse). Transvaginal anterior or posterior wall repair using transobturator mesh implants with or without concomitant transobturator sling procedure. Mean age was 51.4 ± 5.2 years. Mean operating time was 47.6 ± 23.4 minutes, and the mean hospitalization period was 3.8 ± 1.6 days. After initial decrease during the first 3 months, patients experienced a steady improvement in their sexual function. At 24 months postoperatively, the total mean FSFI score reached significantly higher values compared to the baseline (P = 0.023). Furthermore, pain-free intercourse improved during the follow-up reaching mean score of 4.27 ± 0.79 (P < 0.05) after 2 years. Pelvic floor examination at 2 years follow-up showed excellent surgical results with only 3.1% of the patients presenting with stage II vaginal wall prolapse. Surgical repair of symptomatic pelvic organ prolapse using mesh implants results in improvement of major parameters of sexual function. A worsening in pain with intercourse during the initial months postoperatively lessens after 3 months as healing is completed.

Successful Treatment of Infected Ascending Aortic Prosthesis by Omental Wrapping Without Graft Removal

A deep wound infection after a midline sternotomy is a very serious complication. The severity of it can be increased by the presence of prosthetic material. We present a case of a 76-year-old man who had an infection of an ascending aortic graft develop after a Bentall procedure. Rather than following the "traditional" surgical therapy of graft explantation and debridement, we chose to preserve the graft and protect it by omental translocation. The relative merits of this therapeutic approach are outlined and discussed. The patient was discharged on the postoperative day 6 after an uneventful postoperative course.

Preventing Staphylococcus aureus infection in the renal unit.

Staphylococcus aureus is an important cause of morbidity and mortality in the renal unit setting. It is the leading cause of haemodialysis‐related bacteraemia and peritoneal dialysis catheter exit‐site infection,1–,4 and an important cause of peritoneal dialysis‐related peritonitis.5 Since many such infections are potentially preventable, the institution of strategies that reduce infection rates represents an important element in the care of this patient group. This review examines the basis of prevention, together with its likely benefits and possible disadvantages. S. aureus carriage has been described as falling into three patterns in healthy adult populations, with approximately 20% of individuals being persistent carriers, about 60% intermittent carriers and 20% persistent non‐carriers (reviewed in reference 6). Carriage rates are considered to be higher in the renal unit setting, although reported rates vary between centres from 37.5% to 57% for those on CAPD,7–,10 and 37%–62% for those on haemodialysis.8,11–,13 Possible explanations for this variation include sensitivity of swabbing and microbial culture techniques, the number of swabs taken over time and the number of body sites sampled. Why renal unit patients should have higher carriage rates than the healthy population is not clearly understood, although probable contributors include immunodeficiency, the presence of prosthetic material and frequent breaches of the skin associated with venepuncture. Carriage of S. aureus is an important risk factor for infection with this organism. Carriers undergoing haemodialysis have higher rates of S. aureus bacteraemia, and those receiving continuous ambulatory peritoneal dialysis (CAPD) have higher rates of exit‐site infection and peritonitis, compared with non‐carriers.7,8,14–,22 Comparison of carriage and infecting S. aureus isolates indicates that individuals are commonly infected with their own carriage isolate,8,16,18,23,,24 an observation that underpins prevention strategies. A second …

Infectious endocarditis in children

With the object of analyzing current characteristics of infectious endocarditis (IE) in children, we carried out a retrospective study of 23 cases of IE in children under 15 years of age seen at the Hospital Ramón y Cajal in Madrid (Spain) between 1977 and 1985. The incidence was high (1.3 cases per 1000 children admitted). The male/female ratio was 2:1. Eight patients were under 2 years of age and 15 over 2 years, the majority being adolescents. The two groups presented marked etiological and prognostic differences. Congenital heart disease was the predisposing factor in 20 of the 23 cases. Streptococcus viridans (nine cases) and Staphylococcus aureus (eight cases) were the most frequent organisms. Fourteen cases were on a native valve and nine were secondary (seven of these on prosthetic patches). In spite of advances in therapy, IE continues to be a severe illness: the mortality rate in our series was 26%. Factors associated with a poor prognosis were: age less than 2 years, Staphylococcus aureus as the causative agent, and the presence of prosthetic material.